DRIVING EXPERIENCE

CLASS OF / TYPE OF EQUIPMENT / DATES / APPROX.NO.OF
EQUIPMENT / (VAN,TANK,FLAT,ETC.) / FROM / TO / MILES (TOTAL)
STRAIGHT TRUCK
TRACTOR AND SEMI-TRAILER
TRACTOR - TWO TRAILERS
OTHER
ACCIDENT RECORD FOR PAST 3 YEARS OR MORE
(ATTACH SHEET IF MORE SPACE IS NEEDED)
DATES / NATURE OF ACCIDENT / NUMBER / NUMBER / CHEMICAL
(HEAD-ON, REAR-END, UPSET, ETC.) / FATALITIES / INJURIES / SPILLS
YES / NO
YES / NO
YES / NO
TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)
(ATTACH SHEET IF MORE SPACE IS NEEDED)
DATE CONVICTED / VIOLATION / STATE OF VIOLATION / PENALTY
(month/year) / LOCATION / (forfeited bond, collateral and/or points)
  1. Have you ever been denied a license, permit or privilege to operate a motor vehicle? Yes____ No _____

If yes, explain ______

  1. Has any license, permit or privilege ever been suspended or revoked? Yes_____ No _____

If yes, explain ______

EMPLOYMENT RECORD

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).

Must list the complete mailing address: street number and name, city, state and zip code.

Any gaps in employment and/or unemployment must be explained. Include dates (month/year) and reason.

  1. Last employer name: ______

Address: ______

______

Salary: ______Position held from ______to______

Reason for leaving______

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? (Y/N) ______

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40? (Y/N) ______

  1. Second last employer name: ______

Address: ______

______

Salary: ______Position held from ______to ______

Reason for leaving ______

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? (Y/N) ______

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40? (Y/N) ______

  1. Third last employer name: ______

Address: ______

______

Salary: ______Position held from ______to ______

Reason for leaving ______

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? (Y/N) ______

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlled substances testing requirements as required by 49 CFR Part 40? (Y/N) ______

TO BE READ AND SIGNED BY APPLICANT

I authorize you to make sure investigations and inquiries to my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s} may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company. "I understand that information I provide regarding current and/or previous employers may be used, and those employer(s} will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d} and (e). I understand that I have the right to:

  • Review information provided by current/previous employers;
  • Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and
  • Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s} and I cannot agree on the accuracy of the information."

______

DATE APPLICANT'S SIGNATURE

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge.